Severe impairment (Child-Pugh C)
Should only be used if benefit outweighs risk
Mild to moderate (Child-Pugh A/B)
Standard loading dose then reduce maintenance by 50%
Requires Infectious Disease consultation for use OR completion of the Restricted Antimicrobial order form for approved indications
IV: 6 mg/kg IV every 12 hr x 2 doses then 4 mg/kg IV every 12 hr
PO: 400 mg PO evey 12 hr x 2 doses then 200 mg PO every 12 hr
Dose reduction may be required if low body weight (< 40 kg)
Broad-spectrum antifungal therapy needed and one of the follwoing criteria met:
SCr >2.5 or doubled from baseline
Patient receiving tacrolimus, cyclosporine, aminoglycoside, or cyclophosphamide
BMT or solid organ transplant patient
Candida infections both mucocutaneous and invasive - i.e. Candidemia.
Antifungal prophylaxis in immunocompromised patients.
Therapeutic drug monitoring may be helpful to ensure adequate concentrations and exclude toxicity (Discuss with ID).
Baseline LFTs and weekly for the first month
Serum trough levels at steady state (5-7 days). Target 2-5 mcg/ml
QTc interval in patients at elevated risk
Hepatic enzyme abnormalities
Rash - up to 20%
CYP450 interactions ++.
Other QTc prolonging agents.
Recommend review of pt medications due to high frequency of significant interactions.
Antimicrobial class: Triazole antifungal, Second generation
Pregnancy category: D
CSF penetration: Therapeutic
Lung penetration: Therapeutic
Urine penetration: Poor